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Geriatric Assessment

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					 GERIATRIC
ASSESSMENT


      Gail Gray
 MSc, MD, CCFP FCFP
              CASE HISTORY

   A 70 year old woman is
    brought to your office
    by her family.

   The husband says his
    wife is not doing very well,
    although she does not seem sick.
              CASE HISTORY

   Recently she is not
    eating well and has
    lost weight.

   She sits in her chair doing nothing for most of the
    day. She does not talk much and often seems
    confused. Sometimes she forgets to bathe herself
    and seems unclean.
 WHAT DO YOU WANT TO
ASSESS IN THIS WOMAN?

        Nutrition
    Physical function
    Cognitive function
  Psychologic function
     Social support
 Vision, Hearing, Teeth
      Medications
 WHAT DO YOU WANT TO
ASSESS IN THIS WOMAN?

        Nutrition
    Physical function
    Cognitive function
  Psychologic function
     Social support
 Vision, Hearing, Teeth
      Medications
           SCREENING
         FOR NUTRITION

Weigh the patient at each visit.

Ask the husband to write
down on paper:
 24-hour food record

 72-hour food record
 WHAT DO YOU WANT TO
ASSESS IN THIS WOMAN?

        Nutrition
    Physical function
    Cognitive function
  Psychologic function
     Social support
 Vision, Hearing, Teeth
      Medications
     SCREENING
FOR PHYSICAL FUNCTION

 ask about ADLs:
   feeding, dressing, toileting, bathing,
   continence (urine and bowel), transferring



 "Get Up and Go" Test
INDEPENDENCE IN ADLs

Regaining                         Losing function
function after                    during a chronic
an acute illness                  illness
                   feeding
                   transferring
                   toileting
                   dressing
                   bathing
      “GET UP AND GO” TEST

   Starting from a standard chair, have the
    patient stand up, walk about 2 meters
    across the room, turn, walk back and sit
    down.

   The patient should use his/her normal
    walking aide (cane, walker).
        “GET UP AND GO” TEST

   assesses ability to stand and sit
       ?muscle power
   assesses gait and posture
       ?gait disturbance
   assesses ability to turn around
       ?loss of balance
       ?complaint of dizziness
        “GET UP AND GO” TEST

   normal time to complete is 7-10 seconds

   if > 10 seconds:
       limited ability to do physical activity
       at risk for falling


   if >20 seconds:
       needs full evaluation of physical function
 WHAT DO YOU WANT TO
ASSESS IN THIS WOMAN?

        Nutrition
    Physical function
    Cognitive function
  Psychologic function
     Social support
 Vision, Hearing, Teeth
      Medications
NORMAL       DEMENTIA
AGING

 Cognitive   Cognitive
  Decline     Decline

                +
             Functional
              Decline
        RISK FACTORS
        FOR DEMENTIA
age over 65
female gender
systemic disease
   hyperlipidemia, systolic hypertension, AS
sociocultural history
   low education, alcohol abuse
family history
   apo E4 allele
DIAGNOSTIC CRITERIA
    FOR DEMENTIA

   memory deterioration
   at least one of
        aphasia
        agnosia

        apraxia

        impairment of executive functions

   progressive decline in daily functioning
     DIAGNOSTIC CRITERIA
         FOR DEMENTIA

   aphasia – difficulty remembering names, reading
    and writing
   agnosia – inability to recognize familiar people,
    places and objects
   apraxia – inability to perform motor functions
    (getting dressed, copying a pattern)
   impairment of executive functions – inability to
    plan, execute and modify an event
      SCREENING
FOR COGNITIVE FUNCTION


 normal office conversation

 Mini Cognitive Function test (Mini Cog)

 Mini Mental Status exam
                     MINI COG

   Ask the patient to remember 3 items
       apple, bicycle, flower


   Ask them to draw a clock
    with the hands showing
    10 minutes past 11.

   Ask them to tell you the names of the 3 items.
                       SCORING

   Give one point for each item recalled after
    the clock has been drawn
   Score:
       positive screen for dementia
          Score of 0
          Score of 1 or 2 with an abnormal clock

       negative screen for dementia
          Score of 3
          Score of 1 or 2 with a normal clock
MINI MENTAL STATUS EXAM

    used for screening for dementia
    widely used over many years
    has been validated in many countries
    standardized to reduce variation in test results

  used to monitor progression of cognitive deficits
  results can be used to determine the stage of
   disease
MINI MENTAL STATUS EXAM

  takes only 5-8 minutes to do
  it assesses
     orientation
     attention
     memory
     language
  it is scored out of 30
          CASE HISTORY


The 70 year old lady scores 20
 on her MMSE.

What does this mean?
MINI MENTAL STATUS EXAM
 The maximum number of points is 30.

 Score
 27 – 30:   normal cognition
 21 – 26:   mild impairment
 10 - 20:   moderate impairment
  0 - 9:     severe impairment
      HOW DOES THE MMSE
    TRANSLATE TO EVERYDAY
           LIVING?
   20-25:
       can keep appointments, travel alone
       can use telephone, make meals

   15-20:
       can use home appliances
       can select clothes, dress self, bathe, use toilet

   10-15:
       can feed self
       can clear a table, walk
    LIMITS TO THE MMSE


 not sensitive in early dementia
 no evaluation of executive functions
 does not distinguish between the different
  types of dementia
 not useful in very advanced dementia
TYPES OF DEMENTIA
NATURAL COURSE OF
VASCULAR DEMENTIA
    NATURAL COURSE
OF ALZHEIMER’S DISEASE
      DIAGNOSTIC CRITERIA
    FOR ALZHEIMER’S DISEASE

   presence of dementia
   deficits in 2 or more areas of cognition
   progressive worsening of memory & cognition
   no change in consciousness
   no systemic or brain disorders that could
    account for the dementia
AMYLOID PLAQUES
NEUROFILBRILLARY
    TANGLES
   EARLY SIGNS OF
ALZHEIMER’S DISEASE
   loss of recent memory
   difficulty finding the right word
   difficulty learning new things
   spatial disorientation
   apathy, depression

 no behaviour problems
 normal motor function
   LATE SIGNS OF
ALZHEIMER’S DISEASE
   remote memory loss
   expressive and receptive aphasia
   misidentification of familiar persons/places
   needs help with all ADLs
   mood changes

 behavioural disturbances
 diminished motor function
    DIFFERENTIAL
DIAGNOSIS OF DEMENTIA

     depression

     delirium

     drugs

     metabolic disorders
 WHAT DO YOU WANT TO
ASSESS IN THIS WOMAN?

        Nutrition
    Physical function
    Cognitive function
  Psychologic function
     Social support
 Vision, Hearing, Teeth
      Medications
MOOD DISORDERS
        RISK FACTORS
       FOR DEPRESSION

   first degree relative with mood disorder
   female > male
   past or current abuse/trauma
   stressful life events
   loss
   caretaking responsibilities
        DIAGNOSIS
      OF DEPRESSION

   depressed mood

   5 of 9 symptoms

   present for more than 2 weeks

   with impairment of overall functioning
  SYMPTOMS
OF DEPRESSION
S   sleep disturbance
A   anxiety
D   depressed mood
I     interest loss
F    fatigue
A    appetite change
C   concentration loss
E   esteem loss
S   suicidal thoughts
           SCREENING
         FOR DEPRESSION

 ask two questions about depression

 ask about warning signs of depression
        “SALSA”


 is there any history of recent loss?
      health, memory, mobility, spouse, friends
          TWO QUESTIONS
         ABOUT DEPRESSION


   Do things often give you
    pleasure?

 Do you often feel sad?
“SALSA” SCREENING TEST

S    sleep problems

A    anhedonia

LS   low self-esteem

A    appetite decreased
TO DIAGNOSE & STRATIFY
      DEPRESSION

    Hamilton Rating Scale for Depression
    Beck Depression inventory
    Geriatric Depression Scale

    Cornell Scale for Depression in Dementia
      HAMILTON RATING
    SCALE FOR DEPRESSION

   "gold standard"
   21 question survey
   completed by physician
   not ideal for older patients
   somatic questions may be positive in non-
    depressed older person
 WHAT DO YOU WANT TO
ASSESS IN THIS WOMAN?

        Nutrition
    Physical function
    Cognitive function
  Psychologic function
     Social support
 Vision, Hearing, Teeth
      Medications
            SCREENING
        FOR SOCIAL SUPPORT

   ask about instrumental activities of daily
    living (IADLs)

   identify needs
   ask about people/services already available
    in the home
       family, friends, church
INSTRUMENTAL ACTIVITIES
 OF DAILY LIVING (IADLs)

     preparing the meals
     doing the shopping
     doing the housework
     using the telephone
     looking after financial affairs
     using transportation appropriately
    FACTORS
AFFECTING IADLs
 WHAT DO YOU WANT TO
ASSESS IN THIS WOMAN?

        Nutrition
    Physical function
    Cognitive function
  Psychologic function
     Social support
 Vision, Hearing, Teeth
      Medications
                 SCREENING
                 FOR VISION

   always ask about visual loss

 with one eye covered, have
the patient read a sentence
     repeat with the other eye
     covered

   Snellen chart
                   SCREENING
                  FOR HEARING
   office screening
       high frequency sounds
            listen to a watch ticking
       medium frequency sounds
            whisper from 20cm away
       low frequency sounds
            rub your fingers together


   audiogram
              SCREENING
              FOR TEETH

   ask about pain with
    eating
   visually check the
    teeth, mouth, tongue
   if dentures, remove them
    and check oral cavity
 WHAT DO YOU WANT TO
ASSESS IN THIS WOMAN?

        Nutrition
    Physical function
    Cognitive function
  Psychologic function
     Social support
 Vision, Hearing, Teeth
      Medications
            SCREENING
         FOR MEDICATIONS

    ask the husband
    to bring in ALL the
    medications in the
    house (prescribed
    meds, OTC, herbal
    preparations and vitamins)
             SUMMARY OF
           SCREENING TESTS
   Nutrition           weight: 24 hour food record
   Physical function   "Get up and Go" test
   Cognition           Mini cog test: MMSE
   Psychosocial        Hamilton depression score
   Social support      ask about IADLs
   Vision              Snellen chart
   Hearing             3 tests, audiogram
   Dental              visual inspection
   Medications         bring in to office
         SCHEDULE OF VISITS

First visit
     assess nutrition and ADLs


Second visit
     clarify function using specific assessment tools


Third visit
      monitor function, caregiver support and home
      environment
 GERIATRIC
ASSESSMENT

				
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posted:2/27/2012
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